Treating Depression in Children and Adolescents - Wisconsin

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					School Refusal: Concepts and

       Dave Skripka, MD
             We’ll cover…
• Definitions and scope of problem
• Which psychiatric and family disorders are
  more commonly seen in kids who refuse
• Making sense of and managing individual
• Please throw in comments or questions at
   Definitions here are slippery!
• Some use “school refusal” broadly to mean
  any habitual failure to attend school for any
• Others use it very narrowly to refer to child-
  driven refusal associated with an anxiety
• May or may not include “truancy” (skipping
  school with simple disregard for rules)
• Often used interchangeably with “school
  phobia” or “school avoidance”
         School Refusal (SR)
            my definition today
• “A pattern of resisting or refusing to attend
  and stay the day in school, due at least in
  part to anxiety or mood problems”
• Can include kids who don’t attend school,
  who leave early, or who resist mightily
• Can include kids who are anxious or sad for
  reasons other than an internal disorder,
  provided the emotions are driving the
  avoidance of school
• Typically refers to older children or
  adolescents skipping school as part of a
  pattern of antisocial behavior or disregard
  for rules, not associated with anxiety or
  mood problems.
• I don’t intend to focus on clear cases of
  truancy, although there are kids who show
  elements of both truancy and SR!
 How common is School Refusal
• Roughly 2-5% of school age children,
  depending on the study and definition
• May peak at ages corresponding to
  school transition times (beginning next
• Similar rates in girls and boys
    SR can worsen and be worsened
•   Academic failure
•   Peer problems
•   Family dysfunction
•   Likelihood of hospitalization
   Why do kids refuse school?
• School refusal is a behavior, not an illness
  or syndrome
• Different kids have varying causes
• Knowing trends and common “profiles” is
  helpful, but each child needs individual
  assessment of a number of variables
           The obvious!
A child will refuse school when there are
stronger reasons for refusing than there
are for attending.

Think of a tug of war occurring every day
in every child. For most kids, attending
school wins out handily.
Toward School/Away from home
• Peer connection and approval
• Parental approval and sanction of school
• School adults approval and sanction
• Feelings of competence and mastery in learning
• Developmentally normal drive to separate from
• Pain or conflict associated with staying home
      Toward Home/Away from
• Anxiety about school social setting (phobia,
• Anxiety or frustration about academics
• Anxiety about separating from family
• Physical or mental pain associated with attending
• Parental approval and sanction to stay at home
• School adult approval and sanction to stay at home
• Lack of energy or motivation (inertia=home)
• Family conflict (if need to be at home, protect)
• Specific interests, attention or reinforcers at home
         More on these forces

• Most SR kids have a number of forces that add up
  to produce refusal
• The forces which initially cause the behavior may
  not be the same as those that maintain the
  behavior (child with medical illness later delays
  return to school)
• Changing just some of the forces may be enough
  to win the tug of war; conversely kids attending
  school may begin to refuse with seemingly small
            Assessment of SR
• No substitute for a good interview with child and
• The School Refusal Assessment Scale (SRAS) is
  one assessment instrument with demonstrated
  reliability and validity. Child, teacher, and parent
  versions investigate a number of variables. There
  are associated guides for therapists and families
  using cognitive-behavioral methods to address
  problem areas (
• Mental health referral can be invaluable,
  especially where psychiatric disorders are
    Common SR patterns in children
    with associated psychiatric illness

•   Primarily anxiety based
•   Primarily depression based
•   Mixed anxiety and depression
•   Others
               Anxious SR

• The best outlook with proper intervention
• Almost without exception, have any number
  of somatic symptoms (head/stomach pain)
• Important to distinguish if fear of school
  (social or specific phobia, bullying) versus
  fear of leaving home (separation anxiety
  disorder, home discord, agoraphobia)
• Other anxiety disorders can be present as
              Depressed SR

• Depression or Dysthymia treatable, but in children
  is often missed by adults
• May be more common in kids with learning
  disabilities and academic problems
• Can affect energy and motivation generally, but
  can also worsen preexisting problems with peers,
  family, other adults, and academics
• Outlook for treatment generally good, though may
  be less responsive to simple behavioral
 Mixed Anxious/Depressed SR
• Symptoms of anxiety and depression
• Much poorer prognosis than either
  diagnosis alone
• Often highest levels of somatization, and
  most severe behaviors and symptoms
       Other SR presentations
• Socially impaired: Often socially marginalized,
  autism spectrum, personality disorder. A lack of
  social drive/success or self-centered view of the
  world drives child to avoid school. Very difficult to
  motivate externally.
• Oppositional “Externalizers”: Long history of
  resistance to adult wishes and temper tantrums.
  Avoids school in the context of defiance or conflict.
              Family Matters!
• Parental attitudes and family functioning are
  important factors in determining school attendance
• Families of SR kids are more likely to rate high
  degrees of family conflict, enmeshment, and
• Single parent families are overrepresented in SR
• Anxiety SR pattern kids may have less family
  dysfunction than other SR patterns
• Regardless of theoretical contributions to the
  problem, family dysfunction can make
  implementing solutions difficult
   Clinical Treatment Options
• Cognitive/Behavioral treatments
• Educational/Psychosupportive approaches
• Medication treatment of associated
• Family Therapy
 Clinical Treatment, continued

• There is no uniform clinical treatment
  warranted for all SR behavior
• “Cognitive Behavioral” strategies refers to a
  broad category of interventions from a
  number of professions or parents. The key is
  APPLYING concepts in the real world in a
  concrete way.
• Medications, particularly SSRI
  antidepressants, appropriate as part of a
  comprehensive plan in cases of
 School management of SR

I’m no expert in how schools should
accomplish anything! Here are some
Physician/School Management of
• Therapeutic alliances may be difficult with
  many SR students and families. However,
  some common goals have to be identified
  and stressed.
• AMBIVALENCE is common, in many families
  as well as nearly all SR kids. Ask about
  parental fears or perceptions that the school
  attendance is painful or harmful for their child.
• Be aware of and (privately) acknowledge
  one’s own attitudes, anger, or frustration
  toward particular families one might find
• Beware of snap assessments that a case of
    School Management of SR
• Screening for anxiety and depression are
  key in cases of SR. School medical
  professionals are in a prime position to
  notice somatization and to “pick up” these
• Treat or refer to mental health treatment if
  these are suspected.
• Schools play a vital role in advocating for
  participation in mental health treatment
  even after referral.
  School Management of SR

• Legal sanctions and consequences
  should NOT be withheld in cases of
  recurrent absence except in cases
  where there is a clear medical illness
  (with excuse).
• In cases of anxiety or depression,
  consequences shouldn’t be withheld
  except as part of a specific behavioral
• Early intervention is key, as prognosis
•   Cases?
•   Questions?
•   Comments?
•   Disagreements?
•   Observations?
             Written Resources

• Kearney CA, Albano AM. When Children Refuse School:
  A Cognitive-Behavioral Therapy Approach--Therapist
  Guide. San Antonio, TX: Psychological Corporation
• Kearney CA, Albano AM. When Children Refuse School:
  A Cognitive-Behavioral Therapy Approach--Parent
  Workbook. San Antonio, TX: Psychological Corporation

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